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1.
Int Heart J ; 60(4): 822-829, 2019 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-31257338

RESUMO

Atrial fibrillation (AF) is an independent risk factor for intracranial hemorrhage in patients receiving recombinant-tissue-type plasminogen activator (rt-PA) thrombolytic therapy. Research showed that patients with acute ischemic stroke (AIS) could benefit from multimode computed-tomography- (CT-) guided intravenous thrombolysis over 4.5 hours. The medical data of patients with AIS in our center were retrospectively reviewed, and the data of the multimode CT-guided thrombolytic therapy or nonthrombolytic therapy within different time windows (3-9 hours) were evaluated. 134 AIS cases were selected successfully and divided into three groups: patients with AF treated by rt-PA (AF rt-PA), patients with AF not treated by rt-PA (AF non-rt-PA), and patients without AF treated by rt-PA (non-AF rt-PA). After correcting for the baseline NIH Stroke Scale (NIHSS), sex, age, and hypertension data, the comparison results showed that the NIHSS improved significantly at hospital discharge for rt-PA-treated patients (n = 47) compared to non-rt-PA-treated patients with AIS (n = 31) with AF (P = 0.0156). The NIHSS evaluation at 90 days of follow-up also improved in rt-PA-treated patients (P = 0.0157). The NIHSS at hospital discharge was higher in AF rt-PA-treated patients compared to non-AF rt-PA-treated patients (P = 0.0167) after correction; the difference was not statistically significant at 90 days of follow-up (P = 0.091). Our research showed that the neural function improved after 3-9 hours of thrombolytic therapy with rt-PA in patients with AIS and AF. If there is no thrombolytic taboo, the patients could benefit from the thrombolytic therapy, although the onset time window has been extended to 9 hours.


Assuntos
Fibrilação Atrial/complicações , Isquemia Encefálica/tratamento farmacológico , Tomografia Computadorizada Multidetectores/métodos , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Doença Aguda , Administração Intravenosa , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiologia , Feminino , Fibrinolíticos/administração & dosagem , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
2.
J Stroke Cerebrovasc Dis ; 28(9): 2475-2480, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31256984

RESUMO

STUDY OBJECTIVE: Stroke mimics may be difficult distinguish from acute ischemic strokes and are often treated with alteplase though not by intent. We report the characteristics, frequency, and outcomes of stroke mimics treated at our institution. Using our data, we then explore how the inclusion of stroke mimics in stroke outcomes research may be an important source of bias. METHODS: We retrospectively identified all patients treated with alteplase in our emergency department from August 2013 to December 2017 for suspected acute ischemic stroke. We collected the following variables: gender, age, risk factors (hypertension, diabetes, and atrial fibrillation), admission glucose, admission National Institute of Health Stroke Scale, admission mean arterial pressure, onset-to-treatment time, adverse events, discharge diagnosis, length of stay, discharge NIHSS, discharge destination, and 3 month modified Rankin score. RESULTS: One hundred and eighteen patients were treated with alteplase for suspected acute ischemic stroke of which 33 (27.9%) were stroke mimics. Compared to ischemic strokes, stroke mimics were younger (median age 53 versus 69; P < .0003); were less likely to have vascular risk factors (hypertension [51.5% versus 78.8%; P < .005] diabetes (9.1% versus 32.9%; P < .007), and atrial fibrillation (3.0% versus 23.5%; P < .006). The most common stroke mimic was transient ischemic attack (33.3%). Stroke mimics were significantly more likely to be discharged home (75.8% versus 41.2%; P < .002). Outcomes unadjusted for stroke mimics led to artificial inflation of a favorable discharge destination. CONCLUSIONS: Inclusion of stroke mimics led to an artificial inflation of a favorable discharge destination for our entire cohort. Our study highlights the potential for bias in reporting favorable outcomes if appropriate adjustment accounting for stroke mimics does not occur.


Assuntos
Pesquisa Biomédica/métodos , Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Projetos de Pesquisa , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Adulto , Idoso , Viés , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Diagnóstico Diferencial , Avaliação da Deficiência , Serviço Hospitalar de Emergência , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Sistema de Registros , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
3.
J Stroke Cerebrovasc Dis ; 28(9): 2488-2495, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31277995

RESUMO

BACKGROUND AND OBJECTIVE: Current standard practice guidelines recommend ICU admission for ischemic stroke patients treated with intravenous tissue plasminogen activator (IV-tPA). More recently, the trend in stroke care is to broaden eligibility for IV thrombolysis. Two examples are a more liberal inclusion criteria known as SMART criteria (sIV-tPA), and the transfer of patients to comprehensive stroke centers (CSC). The present study characterizes ICU interventions in these patients. Understanding which stroke patients that require ICU-level care may allow for placement of patients in the appropriate level of care at hospital admission. METHODS: We performed a retrospective review of consecutive transfer and nontransfer sIV-tPA-treated patients admitted to the ICU at a CSC. We evaluated the frequency, timing, and nature of ICU interventions. RESULTS: Three hundred and thirty one patients were treated with sIV-tPA and 42% required ICU interventions during ICU admission. Of patients requiring ICU interventions, 98% had an ICU intervention performed in triage, prior to admission. National Institute of Health Stroke Scale score only had a moderate association to requirement of ICU interventions. Neither transferring patients to a CSC nor the number of standard IV-tPA contraindications increased ICU interventions. CONCLUSIONS: Liberalized IV-tPA administration did not increase ICU interventions. Nearly all patients that required ICU interventions declared this need in triage, prior to ICU admission. This timing of ICU intervention use during triage is highly sensitive for whether a patient will require ongoing ICU-level care during hospital admission. Identifying ICU intervention use in triage may allow for more effective placement of post-IV-tPA patients in the appropriate inpatient care setting, leading to better utilization of scarce ICU resources.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Unidades de Terapia Intensiva , Admissão do Paciente , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Triagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Unidades de Terapia Intensiva/normas , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/normas , Seleção de Pacientes , Transferência de Pacientes , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/normas , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Triagem/normas
4.
Medicine (Baltimore) ; 98(24): e16052, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31192964

RESUMO

RATIONALE: Postpartum deep vein thrombosis is a unique condition in diagnosis and treatment. Rivaroxaban, a novel oral anticoagulant, is indicated for acute deep vein thrombosis, but limited data have been reported for postpartum women. Catheter-directed thrombolysis is a common procedure for treating acute deep vein thrombosis, but it is rarely used for postpartum patients, especially after more than 3 months. PATIENT CONCERNS: A 31-year-old Asian woman suffered from progressive erythematous swelling and local heat of the left lower limb after twin delivery. DIAGNOSES: Venous duplex ultrasound examination showed thrombus formation in the left femoral vein and popliteal vein with reduced compressibility. After standard treatment of novel oral anticoagulant therapy for 4 months, we observed only partial improvement of the symptoms, and the condition deteriorated after her ordinary activities. INTERVENTIONS: Venography was performed and a large amount of thrombus lining from left femoral vein to left iliac vein was noted with total occluded left common iliac vein. After catheter-directed thrombolysis and balloon dilatation, better flow was regained and her symptoms improved completely after procedure. OUTCOMES: During a 1-year follow-up without medication, the patient did not complain about leg swelling, exercise aggravation, or any other post-thrombotic symptoms. LESSONS: Pregnancy seems to be a transient provoking factor for deep vein thrombosis, but it is sometimes refractory even during the postpartum period.Follow-up imaging studies should be encouraged to confirm the vessel condition, particularly for applying down-titration or discontinuation strategies of medication.Catheter-directed thrombolysis could be considered as an alternative method for postpartum iliofemoral deep vein thrombosis. Postpartum women usually have favorable functional status and lower bleeding risk.Rivaroxaban is a favorable choice for deep vein thrombosis, but its use in postpartum women is still controversial, and evidence of its effectiveness is not available. Thus, endovascular intervention can be a relatively safe therapy, in addition to anticoagulation therapy for premenopausal patients with recurrent deep vein thrombosis.


Assuntos
Transtornos Puerperais/terapia , Terapia Trombolítica/métodos , Trombose Venosa/terapia , Adulto , Cateterismo , Feminino , Veia Femoral , Humanos , Veia Ilíaca , Período Pós-Parto , Transtornos Puerperais/diagnóstico por imagem , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/etiologia
5.
J Stroke Cerebrovasc Dis ; 28(8): 2337-2342, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31182266

RESUMO

INTRODUCTION: Monitoring of acute ischaemic stroke patients during thrombolysis or thrombectomy is based mostly on frequent physical examinations, since no objective measurement of cerebrovascular haemodynamics is available in routine clinical practice. Near-infrared spectroscopy (NIRS) is a bed-side, noninvasive assessment tool that could help monitor these patients and potentially guide therapeutic interventions. Our goal in this pilot study was to investigate whether NIRS is a suitable method to monitor leptomeningeal collateral circulation via changes in cortical oxygen saturation in the first 24 hours of acute ischaemic stroke. PATIENTS AND METHODS: Our study included 5 patients with acute anterior circulation infarcts. All patients received thrombolytic therapy and 1 had thrombectomy. 24-hour continuous NIRS monitoring was performed on all participants. RESULTS: We aimed to give a detailed description of each NIRS recording and explain how the observed findings could correlate with changes in anterior watershed territory collateral circulation and clinical outcome. CONCLUSION: Our pilot study supports the use of NIRS monitoring in acute ischaemic stroke. We believe that this technique could provide real-time information on the dynamic changes of leptomeningeal collateral circulation and help monitor the effects of thrombolysis and thrombectomy.


Assuntos
Infarto Encefálico/diagnóstico , Infarto Encefálico/terapia , Fibrinolíticos/administração & dosagem , Monitorização Ambulatorial/métodos , Sistemas Automatizados de Assistência Junto ao Leito , Testes Imediatos , Espectroscopia de Luz Próxima ao Infravermelho , Trombectomia , Terapia Trombolítica/métodos , Idoso , Idoso de 80 Anos ou mais , Infarto Encefálico/sangue , Infarto Encefálico/fisiopatologia , Circulação Cerebrovascular , Circulação Colateral , Imagem de Difusão por Ressonância Magnética , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Valor Preditivo dos Testes , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento
6.
Eur J Radiol ; 116: 219-224, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31153569

RESUMO

BACKGROUND: Endovascular treatment is considered a reasonable approach for patients with acute posterior circulation stroke, but it remains uncertain which patients will benefit the most from it. OBJECTIVE: To find independent clinical and angiographic predictors of outcome after endovascular treatment for posterior circulation stroke. METHODS: We evaluated consecutive patients with acute posterior circulation stroke who underwent endovascular treatment in our comprehensive stroke center from January 2015 to December 2017. Good outcome was defined as a modified Rankin score of 0-3 at 90 days. Intracranial atheromatous disease was established on focal stenosis recorded during endovascular treatment. Associations were sought between a good outcome and clinical and angiographic factors. Adjusted logistic regression models were used to define independent outcome predictors. RESULTS: Forty-seven consecutive patients were included: mean age 70.9 ± 12.1 years, median admission NIHSS score, 16 (IQR: 8-30). On univariate analysis, age (p = 0.01), smoking (p = 0.04), hypertension (p = 0.03), successful reperfusion (p = 0.04), presence of extracranial atherosclerosis (p = 0.02), and absence of atherosclerosis (p = 0.03) were significantly associated with a good outcome. On multivariate analysis, age <70 years (odds ratio = 6.20, 95%CI 1.52-25.47, p = 0.01) and absence of intracranial atherosclerosis (odds ratio = 6.45, 95% CI 1.09-38.24, p = 0.04) were independently associated with a good outcome. CONCLUSIONS: Pretreatment determination of the presence or absence of intracranial atherosclerosis can aid management of posterior circulation stroke patients. The absence of intracranial atherosclerosis may have value as a positive selection criterion for endovascular treatment in future trials. The presence of intracranial atherosclerosis could be used as a selection tool in future studies investigating new treatment protocols for this population.


Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares/métodos , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/fisiopatologia , Angiografia Cerebral/métodos , Feminino , Humanos , Arteriosclerose Intracraniana/diagnóstico por imagem , Arteriosclerose Intracraniana/fisiopatologia , Arteriosclerose Intracraniana/terapia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Neuroimagem/métodos , Razão de Chances , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/fisiopatologia , Trombectomia/métodos , Terapia Trombolítica/métodos , Resultado do Tratamento
7.
BMC Neurol ; 19(1): 127, 2019 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-31195995

RESUMO

BACKGROUND: Immune cells are involved in all stages of acute ischaemic stroke (AIS) and possess both neuroprotective and neurodamaging properties. It has been suggested that immune system activation after stroke may be associated with the development of haemorrhagic transformation (HT), which is the main complication limiting the clinical use of intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) for AIS. The purpose of our study was to analyse the association between absolute eosinophil count (AEC) at admission and the occurrence of HT after intravenous rtPA therapy for AIS. METHODS: In this retrospective study we enrolled AIS patients who were treated with rtPA within 4.5 h of symptom onset. Baseline stroke severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS). Patients underwent head computed tomography scans at admission which were repeated 24 h after treatment with rtPA or promptly in case of clinical deterioration. HT was defined as blood at any site in the brain on follow-up head computed tomography scans. Spearman's rank correlation test was used to analyse the correlation between AEC and NIHSS scores. The optimal AEC cut-off value for predicting HT was calculated using the area under the receiver operating characteristic curve. Multiple logistic regression was used to determine the association between AEC included as a binary variable and the incidence of HT. RESULTS: The data of 201 patients was analysed (59.7% females; median age 77 years); 23 (11.4%) of them developed HT. The median of AEC was 62.5% greater in the non-HT group compared to the HT group (0.13 ×  109/l and 0.08 × 109/l, respectively, p = 0.026). No correlation was found between AEC and baseline NIHSS scores (r = 0.061, p = 0.393). AEC ≥ 0.11 × 109/l predicted the occurrence of HT with 69.6% sensitivity and 60.7% specificity. AEC ≥ 0.11 × 109/l was independently associated with a 78% reduction in the odds of developing HT (adjusted odds ratio = 0.223, 95% confidence interval = 0.069-0.723, p = 0.012). CONCLUSION: Higher values of AEC were associated with lower odds of developing HT, thus, AEC at admission could be considered an independent predictive marker of HT after treatment with rtPA for AIS.


Assuntos
Biomarcadores/sangue , Hemorragia Cerebral/etiologia , Eosinófilos , Acidente Vascular Cerebral/complicações , Ativador de Plasminogênio Tecidual/efeitos adversos , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/complicações , Hemorragia Cerebral/sangue , Feminino , Humanos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Curva ROC , Estudos Retrospectivos , Sensibilidade e Especificidade , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/métodos
8.
Medicine (Baltimore) ; 98(20): e15734, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096534

RESUMO

Early treatment of acute ischemic stroke with intravenous thrombolysis therapy (ITT) followed by intra-arterial thrombectomy (IAT) is a promising new treatment option for improving functional outcomes. Identifying patients who will benefit from this treatment combination is important.A total of 92 acute ischemic stroke patients who received ITT and IAT with a minimum of 1-year follow-up were included in the study. All parameters of clinical and imaging examinations at baseline were examined which parameters were significantly correlated with the 1-year functional outcomes (modified Rankin scale [mRS], National Institute of Health Stroke Scale [NIHSS], and Barthel Index) after stroke. Receiver-operating characteristic (ROC) curves analysis was performed to estimate the diagnostic performance of each significantly related parameter. Youden index was used to determine the optimal threshold value. Multivariate logistic regression model analyses were applied to verify the results of predicting the favorable functional outcomes.Immediate postoperation outcome with modified thrombolysis in cerebral infarction grading showed that total of 62 patients qualified for satisfactory result (2b or 3). In predicting NIHSS improvement, ROC curve analysis showed that a cutoff point of vertebral artery pulsatility index (VA PI)-ipsilateral ≤2.3 yields the best diagnostic performance (area under the ROC curve [AUC] = 0.728); in predicting mRS improvement, VA PI-ipsilateral ≤1.92 and internal carotid artery resistance index (ICA RI)-ipsilateral ≤0.71 yield good diagnostic performance (AUC = 0.697 and 0.672, respectively); and ICA RI-contralateral ≤0.70 or plaque index-ipsilateral ≤2 had better diagnostic accuracy (AUC = 0.764 and 0.689, respectively) than other indices to predict Barthel index improvement. The multivariate analysis also showed that these 5 indices were those more powerful and highly significant favorable functional outcomes predictors.Parameters of pulsatility and resistance index from carotid duplex could be easily accessed and noninvasive. The outcome of ischemic stroke patients receiving ITT followed by IAT can be forecasted by these 2 crucial predictors that hint the patients' functional outcomes as well as guiding first line in-charge clinician in terms of decision making.


Assuntos
Isquemia Encefálica/terapia , Artéria Carótida Interna/cirurgia , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Terapia Trombolítica/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Infusões Intra-Arteriais , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Curva ROC , Resultado do Tratamento
9.
BMC Neurol ; 19(1): 86, 2019 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-31053101

RESUMO

BACKGROUND: Although the efficacy of tissue plasminogen activator (tPA) for acute ischemic stroke is well established, rates of tPA use remain low. For clinicians, advocates, and policy-makers seeking to increase tPA treatment rates, it is important to understand what interventions exist and their relative effectiveness. METHODS: We searched PubMed and EMBASE to identify all studies published between 1995 and January 8, 2015 documenting interventions to increase the use of tPA with broadly inclusive criteria. The principal summary measure was the percentage change in rate of tPA administration. Random effects meta-analytic models were built to summarize the effect of intervention compared to control overall and for intervention characteristics. RESULTS: The search yielded 1457 results of which 25 met eligibility criteria. We identified 14 pre-post studies, ten randomized controlled trials, and one quasi-experiment. Included studies targeted their interventions at emergency medical services (EMS) (n = 14), telemedicine (n = 6), and public education (n = 6). In a random effects model, tPA administration was significantly higher in the intervention arm across all studies limiting enrollment to ischemic stroke patients (n = 16) with a risk ratio (RR) of 1.80 (95% confidence interval [CI], 1.45-2.22). A trend towards increased tPA administration was observed for all intervention approaches: risk ratio of 1.73 (95% CI, 1.44-2.09) for EMS, 1.58 (95% CI, 0.72-3.47) for telemedicine, and 1.89 (95% CI, 0.77-4.65) for public education, the latter not restricted to ischemic stroke patients. CONCLUSIONS: Interventions to increase tPA use appear to have considerable effectiveness. Our findings support the use of such interventions to improve stroke outcomes.


Assuntos
Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Humanos
10.
Lancet ; 394(10193): 139-147, 2019 07 13.
Artigo em Inglês | MEDLINE | ID: mdl-31128925

RESUMO

BACKGROUND: Stroke thrombolysis with alteplase is currently recommended 0-4·5 h after stroke onset. We aimed to determine whether perfusion imaging can identify patients with salvageable brain tissue with symptoms 4·5 h or more from stroke onset or with symptoms on waking who might benefit from thrombolysis. METHODS: In this systematic review and meta-analysis of individual patient data, we searched PubMed for randomised trials published in English between Jan 1, 2006, and March 1, 2019. We also reviewed the reference list of a previous systematic review of thrombolysis and searched ClinicalTrials.gov for interventional studies of ischaemic stroke. Studies of alteplase versus placebo in patients (aged ≥18 years) with ischaemic stroke treated more than 4·5 h after onset, or with wake-up stroke, who were imaged with perfusion-diffusion MRI or CT perfusion were eligible for inclusion. The primary outcome was excellent functional outcome (modified Rankin Scale [mRS] score 0-1) at 3 months, adjusted for baseline age and clinical severity. Safety outcomes were death and symptomatic intracerebral haemorrhage. We calculated odds ratios, adjusted for baseline age and National Institutes of Health Stroke Scale score, using mixed-effects logistic regression models. This study is registered with PROSPERO, number CRD42019128036. FINDINGS: We identified three trials that met eligibility criteria: EXTEND, ECASS4-EXTEND, and EPITHET. Of the 414 patients included in the three trials, 213 (51%) were assigned to receive alteplase and 201 (49%) were assigned to receive placebo. Overall, 211 patients in the alteplase group and 199 patients in the placebo group had mRS assessment data at 3 months and thus were included in the analysis of the primary outcome. 76 (36%) of 211 patients in the alteplase group and 58 (29%) of 199 patients in the placebo group had achieved excellent functional outcome at 3 months (adjusted odds ratio [OR] 1·86, 95% CI 1·15-2·99, p=0·011). Symptomatic intracerebral haemorrhage was more common in the alteplase group than the placebo group (ten [5%] of 213 patients vs one [<1%] of 201 patients in the placebo group; adjusted OR 9·7, 95% CI 1·23-76·55, p=0·031). 29 (14%) of 213 patients in the alteplase group and 18 (9%) of 201 patients in the placebo group died (adjusted OR 1·55, 0·81-2·96, p=0·66). INTERPRETATION: Patients with ischaemic stroke 4·5-9 h from stroke onset or wake-up stroke with salvageable brain tissue who were treated with alteplase achieved better functional outcomes than did patients given placebo. The rate of symptomatic intracerebral haemorrhage was higher with alteplase, but this increase did not negate the overall net benefit of thrombolysis. FUNDING: None.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/tratamento farmacológico , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Tempo para o Tratamento , Hemorragia Cerebral/induzido quimicamente , Imagem de Difusão por Ressonância Magnética , Fibrinolíticos/efeitos adversos , Fibrinolíticos/uso terapêutico , Humanos , Imagem de Perfusão , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/efeitos adversos , Ativador de Plasminogênio Tecidual/uso terapêutico , Tomografia Computadorizada por Raios X , Resultado do Tratamento
11.
Tuberk Toraks ; 67(1): 1-7, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31130129

RESUMO

Introduction: As far as we know, left atrium (LA) imaging findings of pre-treatment and post-treatment nonmassive, submassive and massive acute pulmonary embolism (APE) have not been reported in literature. The aim of this study is to assess LA sizes of nonmassive, submassive and massive APE before and after treatment with computed tomography pulmonary angiography (CTPA) and to research whether there are differences between groups. Materials and Methods: Sixty two adult APE patients (21 nonmassive, 31 submassive and 10 massive) who were diagnosed with CTPA and who had post-treatment follow-up images and recorded clinical information were included in the study. Pre-treatment and post-treatment LA sizes of all groups were measured by two radiologists independently. Result: The lowest pre-treatment LA size was found in massive APE and this difference was found to be statistically significant when compared with submassive (p= 0.001) and nonmassive (p< 0.001) groups. In addition, submassive APE patients were found to have lower LA size when compared with nonmassive APE patients (p= 0.006). In massive and submassive APE, post-treatment LA sizes were found to be statistically significantly higher when compared with pre-treatment (p< 0.001 for both groups). However, in nonmassive APE patients, pre-treatment and post-treatment LA size difference was not found to be statistically significant (p= 0.082). Conclusions: As the severity of APE increases, LA size decreases. Thus, a decrease LA size during APE can show increased APE severity. This study reported that LA size increased statistically in post-treatment massive and submassive APE patients when compared with pre-treatment. These results suggest that in APE patients, as a response to treatment, LA size can be an additional parameter reflecting the changes in cardiac morphology.


Assuntos
Volume Cardíaco/fisiologia , Angiografia por Tomografia Computadorizada/métodos , Átrios do Coração/diagnóstico por imagem , Embolia Pulmonar/diagnóstico , Terapia Trombolítica/métodos , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/tratamento farmacológico , Índice de Gravidade de Doença , Adulto Jovem
12.
J Stroke Cerebrovasc Dis ; 28(8): 2207-2212, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31129109

RESUMO

OBJECTIVES: To evaluate the safety of acute ischemic stroke (AIS) therapy in patients with infective endocarditis (IE) with intravenous thrombolysis (IVT) or endovascular therapy (EVT) such as mechanical thrombectomy. METHODS: We conducted a retrospective study of patients who underwent AIS therapy with IVT or EVT at a tertiary referral center from 2013 to 2017, that were later diagnosed with acute IE as the causative mechanism. We then performed a systematic review of reports of acute ischemic reperfusion therapy in IE since 1995 for their success rates in terms of neurological outcome, and mortality, and their risk of hemorrhagic complication. RESULTS: In the retrospective portion, 8 participants met criteria, of whom 4 received IVT and 4 received EVT. Through systematic review, 24 publications of 32 participants met criteria. Combined, a total of 40 participants were analyzed: 18 received IVT alone, 1 received combined IVT plus EVT, and 21 received EVT alone. IVT compared to EVT were similar in rates of good neurologic outcomes (58% versus 76%, P= .22) and mortality (21% versus 19%, P= .87), but had higher post-therapy intracranial hemorrhage (63% versus 18% [P= .006]). CONCLUSION: IV thrombolysis has a higher rate of post-therapy intracranial hemorrhage compared to EVT. EVT should be considered as first-line AIS therapy for patients with known, or suspected, IE who present with a large vessel occlusion.


Assuntos
Isquemia Encefálica/terapia , Endocardite/complicações , Procedimentos Endovasculares/métodos , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Terapia Trombolítica/métodos , Administração Intravenosa , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiologia , Isquemia Encefálica/mortalidade , Endocardite/diagnóstico , Endocardite/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Hemorragias Intracranianas/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Resultado do Tratamento
13.
J Stroke Cerebrovasc Dis ; 28(7): 2031-2037, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31047820

RESUMO

BACKGROUND: Multimodal computed tomography imaging is used to identify eligible patients for intra-arterial treatment. A concern with this method is the multiple use of iodinated contrast material which presents a possible risk of renal toxicity. We compared the safety of intra-arterial treatment versus intravenous treatment during acute ischemic stroke treatment with a focus on renal safety. METHODS: Adult acute ischemic stroke patients who underwent a baseline Multimodal computed tomography, then intra-arterial treatment and/or intravenous treatment were identified. Primary outcomes were acute kidney injury and changes in serum creatinine at 24-72 hours (Δ serum creatinine). RESULTS: A total of 184 patients received intra-arterial treatment, while 68 received intravenous treatment. There were no differences in mean serum creatinine in the 24-72-hour time period, 24-hour urine volume, or rates of acute kidney injury, dialysis, or mortality. Univariate regression analysis identified diabetes mellitus, operation duration and times of embolectomy as predictors of creatinine increase while the multiple regression model identified diabetes mellitus as the only significant predictor. CONCLUSIONS: There were no significant differences in renal safety between the intra-arterial treatment and intravenous treatment groups. Diabetes mellitus may be a predictor of acute kidney injury. The use of Multimodal computed tomography imaging in the selection of patients who could benefit from endovascular therapy is safe.


Assuntos
Lesão Renal Aguda/induzido quimicamente , Isquemia Encefálica/diagnóstico por imagem , Meios de Contraste/efeitos adversos , Procedimentos Endovasculares/métodos , Iohexol/efeitos adversos , Tomografia Computadorizada Multidetectores/efeitos adversos , Imagem de Perfusão/efeitos adversos , Acidente Vascular Cerebral/diagnóstico por imagem , Lesão Renal Aguda/sangue , Lesão Renal Aguda/diagnóstico , Idoso , Biomarcadores/sangue , Isquemia Encefálica/terapia , Tomada de Decisão Clínica , Meios de Contraste/administração & dosagem , Creatinina/sangue , Procedimentos Endovasculares/efeitos adversos , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Infusões Intra-Arteriais , Infusões Intravenosas , Iohexol/administração & dosagem , Masculino , Pessoa de Meia-Idade , Imagem Multimodal/efeitos adversos , Seleção de Pacientes , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Terapia Trombolítica/métodos , Resultado do Tratamento
14.
BMC Neurol ; 19(1): 103, 2019 May 29.
Artigo em Inglês | MEDLINE | ID: mdl-31142273

RESUMO

BACKGROUND: endovascular therapy (ET) is the standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). The role of adjunctive intravenous thrombolysis (IVT) in these patients remains unclear. The present study aims to investigate whether IVT followed by ET (CoT, combined therapy) provides additional benefits over direct ET for anterior circulation AIS with LVO. METHODS: we achieved a single center retrospective study of patients with AIS caused by anterior circulation LVO, referred to our center between January 2014 and January 2017 and treated with ET. Functional recovery (modified Rankin at 3-months follow-up), recanalization rate (thrombolysis in cerebral infarction [TICI] score) and time, early follow-up brain CT scan infarct volume (EFIV) (for recanalized patients only), symptomatic intracerebral hemorrhage (sICH) and 3-month mortality were the outcomes of interests. Independent predictors of the outcomes were explored with multivariable logistic regression. RESULTS: 145 subjects were included in the study, of whom 70 underwent direct ET and 75 were treated with CoT. Functional independence at 3-months was more frequent in CoT subjects compared to patients who received direct ET (mRS score 0-1: 48.5% vs 18.6%; P < 0.001. mRS score 0-2: 67.1% vs 37.3%; P < 0.001); CoT patients had also higher first-pass success rate (62.7% vs 38.6%, P < 0.05), higher recanalization rate (84.3% vs 65.3%; P = 0.009) and, in recanalized subjects, smaller EFIV (16.4 ml vs 62.3 ml; P = 0.003). Mortality and intracranial bleeding did not differ between the two groups. In multivariable regression analysis, low baseline NIHSS score (P < 0.05), vessel recanalization (P = 0.05) and CoT (P = 0.03) were independent predictors of favorable outcome at three months. CONCLUSIONS: CoT appears more effective than ET alone for anterior circulation AIS with LVO, with similar safety profile.


Assuntos
Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica/efeitos dos fármacos , Estudos Retrospectivos , Resultado do Tratamento
15.
Ann Vasc Surg ; 59: 307.e17-307.e20, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31075475

RESUMO

Vascular complications secondary to acute pancreatitis carry a high morbidity and mortality, often because of their hemorrhagic or thrombotic effects. When thrombosis presents, it is typically localized to the splanchnic venous system. In this report, we present a case of acute superior mesenteric artery thrombosis secondary to necrotizing pancreatitis after a laparoscopic cholecystectomy. The patient was successfully treated with catheter-directed thrombolysis and mechanical thrombectomy.


Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Colecistite Aguda/cirurgia , Artéria Mesentérica Superior , Oclusão Vascular Mesentérica/etiologia , Pancreatite Necrosante Aguda/etiologia , Trombose/etiologia , Colecistite Aguda/diagnóstico por imagem , Angiografia por Tomografia Computadorizada , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Artéria Mesentérica Superior/diagnóstico por imagem , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/terapia , Pessoa de Meia-Idade , Pancreatite Necrosante Aguda/diagnóstico por imagem , Trombectomia/métodos , Terapia Trombolítica/métodos , Trombose/diagnóstico por imagem , Trombose/terapia , Resultado do Tratamento
16.
Vasc Med ; 24(2): 122-131, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30950331

RESUMO

Venous thromboembolism (VTE) is a common vascular condition. New medications are available to prevent hospital-associated VTE. Strategies are being studied to increase appropriate diagnostic testing utilization. Management of deep vein thrombosis (DVT) and pulmonary embolism (PE) has evolved with the advent of new anticoagulant options and catheter-directed intervention. In light of this, providers are commonly challenged with the decision regarding inpatient versus outpatient management. Which patients require long-term (> 3 months) anticoagulation is challenging and multiple clinical prediction models may be used to help determine the risk-benefit ratio in each patient. The management of VTE is an ongoing area of research and is rapidly evolving.


Assuntos
Anticoagulantes/administração & dosagem , Fibrinolíticos/administração & dosagem , Terapia Trombolítica/métodos , Tromboembolia Venosa/tratamento farmacológico , Anticoagulantes/efeitos adversos , Tomada de Decisão Clínica , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Seleção de Pacientes , Recidiva , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Tromboembolia Venosa/sangue , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/epidemiologia
17.
J Clin Neurosci ; 64: 134-140, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30952555

RESUMO

Intravenous tissue-plasminogen activator (IV-TPA) treatment in acute ischemic stroke (AIS) patients due to small vessel occlusion (SVO) has been debated because of its small expected benefit and symptomatic intracranial hemorrhage (SICH) risk. Furthermore, data on subgroups of SVO patients are limited. From a prospective multicenter stroke registry database, AIS patients due to SVO within 24 h from onset were selected. Efficacy outcomes were 3-month modified Rankin Scale (mRS) score 0-1 proportion and mRS score distribution. Additionally, subgroup analyses were conducted by age, sex, initial National Institute Health Stroke Scale (NIHSS) score, and presenting limb paresis. This study included 2482 patients: 193 in the IV-TPA group and 2289 in the control group. After adjusting covariates, IV-TPA treatment was associated with an increased mRS 0-1 outcome (adjusted OR [95% CI], 1.56 [1.06-2.29]; P = 0.0249), but was not significantly associated with a favorable mRS shift (1.33 [0.98-1.81]; P = 0.0709). SICH and 3-month death occurred in three (1.6%) and none in the IV-TPA group versus one (0.04%) and 16 (0.7%) in the control group. In subgroup analyses, the IV-TPA effect appeared significantly greater in patients aged ≥80 versus <80 for mRS score distribution (Pinteraction = 0.012). This study showed that, in SVO patients, IV-TPA within 4.5 h may improve functional outcome with a low SICH risk. The benefit appeared more substantial in patients aged ≥80.


Assuntos
Infarto Cerebral/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/epidemiologia , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
18.
Postgrad Med J ; 95(1122): 181-186, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30975729

RESUMO

OBJECTIVES: The National Institute of Health Stroke Scale (NIHSS) is a predictor for the prognosis of acute ischaemic stroke (AIS) and its prediction is time-dependent. We examined the performance of NIHSS at different timepoints in predicting functional outcome of patients with thrombolysed AIS. METHODS: This prospective study included 269 patients with AIS treated with recombinant tissue plasminogen activator (rt-PA). Unfavourable functional outcome was defined as modified Rankin Scale score 4-6 at 3 months after rt-PA treatment. Receiver operating characteristic curves were used to examine the predictive power of NIHSS score at admission and 2 hours/24 hours/7 days/10 days after rt-PA treatment. Youden's index was used to select the threshold of NIHSS score. Logistic regression was used to estimate the ORs of unfavourable functional outcome for patients with NIHSS score higher than the selected thresholds. RESULTS: The threshold of NIHSS score at admission was 12 (sensitivity: 0.51, specificity: 0.84) with an acceptable predictive power (area under curve [AUC] 0.74) for unfavourable functional outcome. The threshold changed to 5 at 24 hours after rt-PA treatment (sensitivity: 0.83, specificity: 0.65) and remained unchanged afterwards. The predictive power and sensitivity sequentially increased over time and peaked at 10 days after rt-PA treatment (AUC 0.92, sensitivity: 0.85, specificity: 0.80). NIHSS scores higher than the thresholds were associated with elevated risk of unfavourable functional outcome at all timepoints (all p<0.001). CONCLUSIONS: NIHSS is time-dependent in predicting AIS prognosis with increasing predictive power over time. Since patients whose NIHSS score ≥ 12 are likely to have unfavourable functional outcome with rt-PA treatment only, mechanical thrombectomy should be largely taken into consideration for these patients.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/fisiopatologia , Fibrinolíticos/uso terapêutico , Recuperação de Função Fisiológica , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Administração Intravenosa , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento
19.
BMC Musculoskelet Disord ; 20(1): 168, 2019 Apr 12.
Artigo em Inglês | MEDLINE | ID: mdl-30979369

RESUMO

BACKGROUND: The treatment of diabetic foot ulcers in this case is complex and multidisciplinary, and an interdisciplinary team is extremely beneficial. CASE PRESENTATION: We performed the intervention on an old type 2 diabetes patient with poor health, whose left toes were severely necrotic. Surgery, including debridement and patella truncation, had positive effects on lower extremity circulation, infection control, cavity treatment, bone destruction, surgical debridement, recovery of foot function, and nursing. After 5 months, the patient's foot ulcer had healed, and walking function was preserved. CONCLUSIONS: Scheduling interventional surgery and debridement are the key point in a complicated diabetic foot ulcers case, and multidisciplinary collaboration in treatment of diabetic foot is significantly important.


Assuntos
Diabetes Mellitus Tipo 2/complicações , Pé Diabético/terapia , Planejamento de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Idoso , Terapia Combinada/métodos , Angiografia por Tomografia Computadorizada , Desbridamento/métodos , Pé Diabético/patologia , Pé/irrigação sanguínea , Pé/diagnóstico por imagem , Pé/cirurgia , Humanos , Imagem por Ressonância Magnética , Masculino , Terapia Trombolítica/métodos , Resultado do Tratamento
20.
Med Sci Monit ; 25: 2727-2734, 2019 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-30980711

RESUMO

BACKGROUND Arteriovenous fistulas (AVFs) are used to provide vascular access for hemodialysis in patients with end-stage renal failure. However, stenosis and thrombosis can compromise long-term AVF patency. The objective of this study was to evaluate catheter thrombolysis with percutaneous transluminal angioplasty (PTA), using a trans-brachial approach, for acutely thrombosed AVFs. MATERIAL AND METHODS This retrospective study examined 30 cases of AVF thrombosis treated between January 1, 2015 and January 1, 2017. All patients received transcatheter thrombolysis with PTA using a trans-brachial approach. AVF patency was assessed after 6 months. RESULTS Thrombolysis with PTA was performed at 2 to 72 h after diagnosis of AVF occlusion due to acute thrombosis, and AVF patency was restored in all patients. After 6 months, the primary and secondary patency rates were 76.7% and 93.3%, respectively. For type I stenosis, primary patency was achieved in 10 of 16 patients (62.5%) and secondary patency was achieved in 14 of 16 patients (87.5%). For type II stenosis, primary patency was achieved in 13 of 14 patients (92.9%) and secondary patency was achieved in 14 of 14 patients (100%). Comparing type I and II stenosis, a significant difference was detected in the rates of primary patency (odds ratio=0.909, 95% confidence interval 0.754-1.096, P=0.049), but not secondary patency (P=0.178), after 6 months. CONCLUSIONS Our study provides preliminary evidence that catheter-directed thrombolysis with PTA using a trans-brachial approach can achieve high patency rates when used to treat acutely thrombosed AVFs.


Assuntos
Angioplastia/métodos , Fístula Arteriovenosa/terapia , Trombose/terapia , Adulto , Idoso , Derivação Arteriovenosa Cirúrgica , Feminino , Oclusão de Enxerto Vascular/cirurgia , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Diálise Renal , Estudos Retrospectivos , Terapia Trombolítica/métodos , Resultado do Tratamento , Grau de Desobstrução Vascular
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